Data from clinical notes: a perspective on the tension between structure and flexible documentation.

Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB
J Am Med Inform Assoc. 2011 18 (2): 181-6

PMID: 21233086 · PMCID: PMC3116264 · DOI:10.1136/jamia.2010.007237

Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.

MeSH Terms (11)

Data Mining Documentation Efficiency, Organizational Electronic Health Records Forms and Records Control Humans Medical Records, Problem-Oriented Natural Language Processing Reference Standards Systems Integration Workflow

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